Everyone wanted Pharma out of it. Now they're gone, leaving a large bill unpaid. Oops. Probably should have thought of that first.

(An aside: no one thinks twice about asking unemployed college kids or their parents to pony up $150k of after tax income for tuition alone for medical school, but asking employed doctors to put up hundreds of tax deductible dollars for CME is somehow drunken buffoonery.)

But the real question is, do we need CME at all?

Don't roll your eyes at me, Superfly, I'm serious. If we really need an artificial system to force doctors to stay current, does this do that?

Here's this month's CME post-test, worth 1/20th of the yearly state requirements:

What does this question teach you? Nothing.

Time is not infinite-- whatever time and energy was spent learning this meant you didn't learn something else. So I ask you again-- does this help me stay current and knowledgeable, or less so?

"Ok, some of it's trivial, but it's the best option we have." Again, brainwashing: if something doesn't work, it doesn't matter that it's better than the other things that don't work. Doing nothing is better than doing the wrong thing that costs money.

It isn't evident that this stuff leads you to be a better doctor. There's a case to be made-- and I'm making it-- that this actually makes you a worse doctor.

II.

Docs pay for CME because it absolves them of having to learn what appears to be an overwhelming amount of information on their own. But then CME becomes the exportation of the particular biases of the isolated class of CME writers. I have ten years of Depakote CMEs that were not funded by Abbott to prove it. Do you have any Dilantin or Neurontin ones? No? "But those drugs don't work." Do you know why you know that? The Depakote guys told you.

You know these CME guys are called, without any irony, "thought leaders", right?

Imagine you paid money for a newspaper that selected and organized the information they thought was important, and trivialized/marginalized anything that didn't fit into the "accepted" paradigms-- for example, a third party candidate during an election. Or, imagine you paid a bunch of guys you don't know $100k to select and organize what they think is important to your child's development, based solely on the reputation of the corporation that hired them.

Imagine that.

II.

Here's why you've never questioned the need for "continuing education": it is designed to self-reinforce the impression of ignorance. The focus is on continuing-- which means you're never done. You must always be left with the feeling that you are actually quite ignorant about the "current" information.

An example of this idea is Dr.Nasrallah's very editorial: the full title is "The $1.2B CME Crisis: Can eleemosynary replace industry support?"

Well, he got me on eleemosynary, I'll admit. But then again, he probably got lots of people-- so why use the word?

In that same way, Nasrallah uses eleemosynary in a post about continuing education to convey an impression of refinement and knowledge-- you're not as smart as him. So it would never occur to you to question the need for further education; you're hooked into his musings about who should pay the bill.

IV.

The argument about CME is structured similarly to the general healthcare debate: what ways can we make this affordable but free of bias and misuse? But the focus on cost vs. commercialism ensures no one notices that a lot of this stuff simply isn't necessary. The number one branded drug in the U.S. is Lipitor and you don't need it. But because CME is a $1.5B industry, no one will allow that question to be asked, not by conscious suppression but because of groupthink and brainwashing. Go ahead, try. You'll be dismissed with the "of course" fallacy ("of course, we need some system for continuing education,;of course, we need to keep doctors current; of course, we need a way to track it; of course, the system's not perfect but it's the best we have").

These are the responses given by those anchored in the system, in the Matrix. They never question the premises. Never question the textbook, the Introduction.

And they are the ones you will pay to have as your teachers and leaders.

Comments

I was diagnosed with depression and not as bipolar for years because I never had a manic episode. But gee, I was bipolar. Got the wrong medication for years because the diagnosis for bipolar says you have to have a manic episode or you're not bipolar. Dumb, dumb, dumb.

Symptoms cannot be taken on their own to mean anything. There is no "correct diagnosis", there are medications that work for you and those that don't. I had to talk my shrink into giving me lamictal because at the time it wasn't even approved for bipolar. Whattayaknow, it works. He thanked me every time I saw him for years for talking him into a treatment that helped a lot of his patients.

Sometimes, patients know what they need. Sometimes they are very good researchers, too. Who says doctors know everything?

I'm for the CME. All learning should be continuous, no one ever knows enough. Doctors need to learn, too. I don't think this particular test is worth much, though. Maybe they should just spend a few hours using Google, like I do.

Is there any evidence at all that CME leads to better practice? I've not seen any research done on this. It seems very like the heavy emphasis on prevention in the current health care debate -- what evidence is there that these things will actually reduce costs and need for treatment?

In my field, we are required to take a 6 hr ethics course in every 2 year license period. I see no evidence that this has made practitioners more ethical, though it does make people far more risk averse because risk prevention is what these ethics courses are really all about.

CME exists because it is part of the guild model. Google "Milton Friedman" and "guild" and start reading. What is a guild? Like the old days: blacksmithing guild, lawyers, medics, etc. You get accepted into a guild as a trainee, then journeyman, then apprentice, then full practitioner. Why? 1. This is how skilled professionals are trained. 2. (Friedman's cynical, economic answer): this allows the guild to maintain the market by regulating who can and cannot do some activity for a livelihood. The guild ideally can get govt to come tell a rogue practitioner to cease and desist whatever practice.

Basically, if a guild behaves a certain way, the govt allows them to continue on with their control over that area of professional activity. So, while the cynical Friedman view is that a guild exists to allow practitioners to control how many people can enter the market, the public story is that the guild self-polices itself for quality and protection of the public.

CME is one of the ingredients used to maintain this status quo, where govt - usually state govt - largely follows the licensing suggesitons of the guild. Other ingredients are the professioal review boards, where you get in trouble with your guild's disciplinary board, as an alternative to civil or criminal court processes. The penalty is generally license probation or suspension, if you transgress enough.

So, if you discontinue CME, the current guild arrangement will start to be dismantled. What is next: dismantle the board exams?

The guy (Goldenberg) pimps for Lilly by slyly thumping Pregabalin. Even though Cymbalta has the same or worse side effect profile! (OBTW, he recommends PROVEN beneficial exercise for Fibromyalgia after 2 MONTHS of psycho-pharmacological brain bombing.)

So, if you discontinue CME, the current guild arrangement will start to be dismantled. What is next: dismantle the board exams?

Hey that would be cool. ABPN wants more than a test these days. There's a long, expensive, time-consuming list of ordeals now for "maintenance of certification" or "MOC", including "feedback modules":

B) Feedback modules (Patient/Peer* Second Party External Review)
• Feedback modules require each diplomate to solicit personal performance feedback from at least five peers* and five patients concerning the diplomate’s clinical activity over the previous three years.
• Each diplomate must then identify opportunities for improvement in the effectiveness and/or efficiency in their practice as related to the core competencies and take steps to implement suggested improvements.
• Within 24 months, each diplomate is required to solicit feedback from at least another five peers* and five patients to see if improvements in practice have occurred. If a diplomate participates in peer review in his/her clinical setting, that institutional activity may also fulfill the PIP Feedback Module criteria.

"Hi Mr. Smith, how are you feeling today? And btw, do I meet your expectations, excede your expectations, or fail to meet your expectations?"

The guys who voted for all this MOC stuff cleverly grandfathered themselves out of it all. Totally unfair, IMHO.

These questions are targeted at psychiatrists who've heard a bit about the (relatively) recent buzz in psychiatry, but don't really understand what's going on. Let's use qutestion 1. The answer is obviously A: true. The reason is that with all this talk about the high rates of comorbidity of bipolar and BPD, or even that they are "really the same thing", the fact is BPD much more often comes with MDD than bipolar.
The thing is that if your psychiatrist doesn't already know that the "right" answers are oversimplifications and mostly wrong, you are in big trouble. And if your psychiatrist is clueless enough to actually think he's learning from these exercises, God help you.

"The guys who voted for all this MOC stuff cleverly grandfathered themselves out of it all."
The Friedman protect-the-ranks cynical view of the guild, to preserve my income, actually holds this time-honored grandfathering pattern as evidence that, while officially declaring that the guild serves to protect the public's welfare, the guilds are actually developed to protect the practitioners' income. We call it: climbing up the ladder to the professional level, THEN raising the level and making the ladder longer AFTER we are already up on the level.

Outright restriction of practice based on numbers won't fly (although it is interesting and complicated to study the phenomenon of certificate-of-need for creating things such as nursing homes). California used to have an oral exam for psychologists, along with the other typical state licensure requirements (complete doctoral program, complete pre-doc internship, pass EPPP, etc.). CA kept increasing the score needed to pass the oral exam. A court case supported the view that this was driven by practitioner's desire to control the market of providers. So, they dropped the oral exam altogether. If you are skilled but have oral test phobia, set up shop in CA.

If protection of the public welfare was truly the goal, already-licensed practitioners would be required to meet new criteria as they emerged.

"If you really think that the "mania" criterion for Bipolar Disorder should be eliminated because of the way YOU felt on Lamictal, then you may benefit from reading his other entries on narcissism"

Anonymous, Donna didn't say that. She merely said that because she didn't have a manic episode, that her bipolarity had been misdiagnosed. The subtext that I got from her statement was that "It is possible to be bipolar without experiencing/exhibiting a manic episode." Not "Bipolar patients NEVER HAVE manic episodes," as you seem to think she said. She also brought up the EXCELLENT point that, sometimes, patients know what they need. Not always, not all patients. Not even all patients all the time. But certainly, a patient who has researched her experiences, symptoms, and reactions to treatments is likely to be an informed patient, maybe more informed about her particular condition than the doctor who has just met her. I'm feeling particularly sensitive about that point, myself, trying to find specialists who would listen to me. I had charts of my symptoms, medications, treatments, responses to treatments. One doctor saw me as "uncooperative" because I told him what medications had not worked for me. I also had more than one doctor ignore what I needed treated, because they were excited to try the very latest medication out on me - regardless of whether it was actually what I needed.

Bipolar is not a "feeling." Patients can not feel that they are "really" Bipolar. It is a man made construct that describes the behaviors/emotional experiences of a group of people. This construct, by definition, requires the existence/history of a manic or hypomanic episode. The entire treatment literature (I more than agree with the fact that the literature sucks, but it is what we have) is based on this construct, and not some unique experiences of individual patients (that is the substance of psychotherapy). In short, if a patient does not have a history of mania/hypomania then they cannot be diagnosed with Bipolar.

So all the non BC docs don't have to go through this stuff, yet they seem to make just a much $ and don't have the preoccupation and related expenses... I've always passed these tests but wonder why I even bother and if it's gotten me into a type of workload that's really outside of what I'm best at (admin vrs clinical). The price is only gonna go up. I'm doing a MOC this year but at the end of next 10 am not so sure :/

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